Patient education has been a winning factor for Woodlawn internal medicine department’s success in improving care for their high-risk diabetic patients. But that education wouldn’t have been possible without teamwork.

Evidence shows that diabetic patients who take the prescribed medications to lower cholesterol and blood pressure and who adopt healthier lifestyles have fewer serious complications down the line, including stroke, heart attack and kidney failure. Nationwide, “non-compliant” diabetic patients account for the costliest and largest group of hospitalized patients.

Woodlawn has a high number such patients, so targeting this hard-to-reach group was promising way to make a big impact. By getting more of their diabetic patients over age 55 to take the prescribed preventive drugs, which includes aspirin, and to modify their lifestyle, the newly formed unit-based team (UBT) in the Mid-Atlantic region knows that those members can expect to see improved health outcomes in the years ahead.

Through an aggressive education campaign, led largely by clinical assistants and nurses, Woodlawn quickly saw encouraging results.

In the first quarter of 2008, only 34.8% of Woodlawn’s diabetic patients over age 55 were actively taking aspirin. By the end of 2008, that percentage jumped to 70.1%. The team is working on ways to accurately track whether patients are taking their prescription medications as well.

“Even though we had done traditional outreach, they didn’t respond,” Woodlawn medical director Robin Davis explained. “So we decided to do more heavy duty ‘in-reach. ‘ ”

The first line of defense: clinical assistants and nurses

All involved say nurses and clinical assistants’ active involvement has been crucial to the clinical improvements.

Many on the team suspected that members were unaware of the diabetes education programs that KP offers members, or didn’t understand the value of taking the classes. Nurses and clinical assistants typically have more opportunities to connect patients with such classes, and they also have more time to help patients understand the long-term benefits of changing their lifestyle and why it’s important to take each medication as prescribed.

“They don’t necessarily know what they’re taking the medication for,” Wheeler said. “If they know how the drug will benefit them, it helps them take it.”

Alert for symptoms

Since education was a key component, every clinical assistant and nurse in Woodlawn internal medicine refreshed their knowledge about the disease by taking Kaiser Permanente’s three-hour introductory diabetes class.

"It was important that we know what (symptoms) to look out for, because a lot of times doctors can’t reach the patients like a nurse can,” said UBT labor co-lead Chiquita Wheeler, RN, a member of UFCW. “We’re closer to the patient.”

Clinical assistant Michelle Knight, an OPEIU member, says it’s not uncommon for her to spot symptoms during the initial screening of a patient, which she then flags for the doctor.

Knight recalled when one woman came in complaining of a bad taste in her mouth and weight loss. Knight recommended that her blood work be done, which later revealed that the woman was diabetic. Knight was responsible for connecting her with a diabetic educator, too.

“My mother always says, ‘They could be your mother, or that could be your father,’” Knight said. “I sit down with them and talk to them (patients). And if I don’t know something, I direct in the right direction.”

Greater appreciation of interlocking roles

Nara Um, MD, the UBT’s former physician co-lead, emphasized the crucial role that clinical assistants and nurses are playing not only in reaching patients, but also how their involvement and input has expanded her mindset as a caregiver.

“I think we physicians sometimes get hung up on the physician view of things. We can become quite one-track-minded….We think, ‘Our patients need this. Why don’t you take this?’ Then I started thinking as if I was not a physician,” Dr. Um said. “If I was the nurse bridging the gap, what I could do to bridge that gap? It was a huge learning experience for me. So it was great having different levels of perspective—what they see as the problem and basis for improvements.”

Barriers addressed

The improvements haven’t come without hurdles to clear. Wheeler says the proactive outreach has been very time-consuming, and many nurses and clinical assistants wind up making most calls during a free minute between patients.

Finding time to meet and maintain communications among the group has also been trying.

“The most challenging thing was not losing the communication between the team and keep the momentum going,” Dr. Um said. “There been a lot of informal communication.”

But on-the-fly brainstorming in team huddles turned out to be a critical method for the team to work through and tweak tests of change, Dr. Um said.

“It was great because every time we met, people would come up with ideas I would never think about,” Um said. “It was great because CAs had a closer patient perspective.”

Next steps

Dr. Um and others on the team see UBTs as a means to improving quality of care for other chronic diseases, and the team has been toying with the idea of using a similar model for their smoking cessation program.